Hyperemia Congestion

Hemodynamics
Hyperemia and Congestion
Dr.CSBR.Prasad, M.D.
Both are vascular events

• Both indicate a local increased volume of

blood in a particular tissue.
• There is increased vascular volume
• Hyperemia is an active process - arteriolar
dilation – arterial side
• Congestion is a passive process -
impaired outflow – venous side - may be
systemic / local
Hyperemia Congestion
Blood volume Increased Increased
Vascular
volume Increased Increased
Mechanism Active – Passive –

chemicals stagnation
Vascular
compartment Arterial side Venous side
Site Usually local Local / systemic

Hydrostatic pressure is increased in both

the conditions, hence
Hyperemia and congestion are always

associated with edema
Conjunctival hyperemia
Conjunctival hyperemia - causes
• Inflammations – conjunctivitis
• Hypercalcemia
• Hyperparathyroidism
• Ataxia – telangiectasia (if the
vessels are tortuous)
Sturge-Weber Syndrome
Blanching (circle)
Congestion
• Distension of blood vessels
• May be an active or passive process
• Reversible condition
Left-sided cardiac failure
Causes:
• 1. Systemic hypertension (most common

cause).
• 2. Ischemic heart disease.
• 3. Mitral or aortic valve disease.
• 4. Primary myocardial disease.

Left-sided cardiac failure
Clinical presentation
1. Due to obstruction to pulmonary vascular out-flow there
is pulmonary congestion and edema.
2. Reduction of renal perfusion causes:
(i) Salt and water retention (ii) Ischemic acute tubular

necrosis
(iii) Impairment of waste excretion causing azotemia.
3. Reduced perfusion of central nervous system causes

hypoxic encephalopathy (irritability to coma).
Right-sided cardiac failure
Causes:
1. Most common cause is the left ventricular failure, causing pulmonary congestion and
raised pulmonary arterial pressure.
2. Intrinsic disease of lungs and pulmonary vasculature causing obstruction to right

ventricular out-flow (cor pulmonale).
3. Pulmonary or tricuspid valve disease.
4. Congenital heart disease in which there is left-to-right shunt.
Example: (i) Patent foramen ovale ; (ii) Patent ductus arterisus and (iii) Interventricular
septal defect.
Other causes:
i) Extracardiac circulatory failure. Example: Haemorrhage ; vasovagal syncope etc.
ii) Impaired atrial filling by external compression. Example: Constrictive pericarditis.

Right-sided cardiac failure
Clinical presentation
1. Congestion and edema of portal and dependent
peripheral sites
(Eg: feet, ankle, sacrum) and effusions in pleura and
peritoneum (ascites).
2. Hepatomagaly - Centrilobular congestion and atrophy of

central hepatocytes (nutmeg liver)
3. Congestive splenomegaly with sinusoidal dilation, focal

hemorrhage followed by hemosiderosis and fibrosis.
4. Renal congestion causes acute hypoxic tubular necrosis.

Normal liver
Normal liver
CVC liver -- Gross
In chronic passive congestion of the liver
(nutmeg liver)
the central regions of the hepatic lobules are

grossly red-brown and slightly depressed
(owing to a loss of cells) and are
accentuated against the surrounding
zones of uncongested tan liver (nutmeg
liver)
CVC – Liver
‘Starry sky’
appearance
in US
Nut meg liver
Nut meg
CVC liver -- microscopy
• Centrilobular necrosis with loss of
hepatocytes dropout and
• Hemorrhage, including hemosiderin-laden
macrophages
• Hepatic fibrosis [In severe, long-standing
hepatic congestion there may even be
grossly evident hepatic fibrosis (cardiac
cirrhosis)]
CVC liver -- Microscopy
In acute hepatic congestion:
• Central vein and sinusoids are distended
with blood
• Central hepatocyte degeneration
• The periportal hepatocytes - may only
develop fatty change.
CVC - Liver
Centrilobular necrosis - causes
NOTE: Because the central portion of the
hepatic lobule is the last to receive blood,
centrilobular necrosis can also occur
whenever there is reduced hepatic blood
flow (including shock from any cause);
there need not be previous hepatic
congestion.
CVC Lung
Pulmonary
edema
CVC Lung - Gross
• The cut surfaces of hyperemic

• tissues are hemorrhagic and wet
CVC Lung - Microscopic
Acute pulmonary congestion:
• alveolar capillaries engorged with

blood
• alveolar septal edema and/or
• focal intraalveolar hemorrhage
CVC Lung - Microscopic
Chronic pulmonary congestion:
• the septa are thickened and fibrotic
• the alveolar spaces may contain
numerous hemosiderin-laden
macrophages (heart failure cells).
Pulmonary edema with a few extravasated RBCs
Heart failure cells
CVC – Lung [ Perl’s stain ]
E N D
goto Hemorrhage

Hyperemia Congestion

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Hemodynamics

Hyperemia and Congestion

Both are vascular events

• Both indicate a local increased volume of

Mechanism Active – Passive –

Site Usually local Local / systemic

Hydrostatic pressure is increased in both

Hyperemia and congestion are always

• 1. Systemic hypertension (most common

• 2. Ischemic heart disease.

• 3. Mitral or aortic valve disease.

• 4. Primary myocardial disease.

2. Reduction of renal perfusion causes:

(i) Salt and water retention (ii) Ischemic acute tubular

(iii) Impairment of waste excretion causing azotemia.

3. Reduced perfusion of central nervous system causes

2. Intrinsic disease of lungs and pulmonary vasculature causing obstruction to right

3. Pulmonary or tricuspid valve disease.

4. Congenital heart disease in which there is left-to-right shunt.

i) Extracardiac circulatory failure. Example: Haemorrhage ; vasovagal syncope etc.

ii) Impaired atrial filling by external compression. Example: Constrictive pericarditis.

2. Hepatomagaly - Centrilobular congestion and atrophy of

3. Congestive splenomegaly with sinusoidal dilation, focal

4. Renal congestion causes acute hypoxic tubular necrosis.

the central regions of the hepatic lobules are

• The cut surfaces of hyperemic

• alveolar capillaries engorged with

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